Insuring Birth Control

So, I’m as big a fan as anyone of the birth control pill, even though I’m an indirect beneficiary of its wonders. And notwithstanding my generally libertarian sympathies, I even think it makes an enormous amount of sense to make subsidized—and in some cases free—contraceptives available to people who genuinely can’t afford them, if only because it’s likely to be a lot less costly to the public in the long run than supporting both the unplanned child and the parents who are a lot less likely to escape poverty once they’ve had that unplanned child. You might even want to set the income bar for the subsidy pretty high, to cover people who, though in no position to afford a child, could afford birth control but would be shortsightedly tempted to risk going without and spend the money on other wants.

Still, I’m puzzled by the general celebration over the news that insurers will be required to cover birth control pills without any copay. I mean, I understand why (employed, insured) women in their 20s and 30s might be personally pleased about the short-term drop in their expenses, but looked at more broadly, it’s just a large predictable cost that’s going to need to get baked into premiums. (The very poor, needless to say, are also most likely to be uninsured.) It just means the cost is now shared between women who do use it and those who don’t. I guess that’s nice for the women who use it, but I’m not sure why it’s necessary or, for that matter, fair.

With limited exceptions—I get that birth control can also be a treatment for certain medical conditions—it seems like birth control is just a predictable cost, not a risk to insure against. It’s like food: You might want to subsidize it for the badly off, but you don’t buy “food insurance,” because there’s nothing to “insure.” You just know you’re going to need food, and so everyone who isn’t poor just buys their own; there’s no good reason to pool the expense.

Actually, it makes less sense even than that, because while everyone needs food, people need birth control only insofar as they’re involved in a sexual relationship (and don’t want children), which (one hopes) is substantially under each policy holder’s control. If that meant everyone in the pool, then requiring coverage would make no difference to anyone, since the exact same cost would just be shifted to the premium. The only reason it makes a difference to anyone is that some people who are having sex get to shift part of their cost to people who aren’t. And that seems a little like salt in the wound: Isn’t it bad enough to not be getting laid regularly without having to pay for the people who are?

If we think it’s of public value to make sure that low income folks have access to contraception when they want it, great, I get that. But it seems like the solution is to just publicly provide it—whether directly or through some sort of voucher. Achieving that goal through the private insurance system just seems bizarre. If, on the other hand, the goal is just to give a free goodie to people who can very well afford it at the expense of those who don’t want or need it… well, that’s just not a particularly worthy goal, is it?

20 responses so far ↓

You note “It just means the cost is now shared between women who do use it and those who don’t. I guess that’s nice for the women who use it, but I’m not sure why it’s necessary or, for that matter, fair.”

It’s the nature of any insurance plan that the costs are shared over the insured pool, in one way or another. So isn’t the cost of an unplanned pregnancy already shared between those who are pregnant and those who are not via insurance?

It seems to me the cost of a pack of BC bills once a month is far less for the co-insured than the cost of an unintended pregnancy.

I’m quite surprised that you jump so quickly to the conclusion that there is a positive cost associated with birth control which would result in higher premiums overall. I would not be at all surprised if the cost were negative: freely available contraceptives mean fewer pregnancies, which themselves are covered by insurance and are very expensive.

I admit I honestly don’t know what the numbers are, but I had assumed that any attempt at rational analysis on the issue by insurance companies had been trumped by political concerns—the contention that pushing contraceptives encourages immoral behavior is (sadly) still not fringe in the US. It again wouldn’t be much of a shock to learn that insurance companies have actually wanted no-copay contraceptives for some time in order to lower costs, and are (quietly) grateful for government regulation letting them to do what they want shielding them from blame for the choice.

This is true only for birth control PILLS. The mandate was birth CONTROL. This includes several very good long-term options that cost $500-$700 upfront and that most insurance plans won’t cover. Most insurance will cover either the pill (with or without copay; mine didn’t require one) or else sterilization. They quite often won’t cover inbetween long-term options, and very few people can just cough up that much money without a twinge to get off of the pill. But the pill is a pain in the butt – you have to maintain the prescription with yearly, inconvenient appointments that make you miss work and you have to keep remembering to go get the thing. Even as a middle-class, transportation-enabled person, I was reduced to calling and begging for an extension which I then had to jump through hoops to pick up on the last day of my old one. Getting someone off of the short-term option and onto the more sure, more convenient option that you actually need to go out of your way to reverse will undoubtedly simplify many women’s lives who want children but not in the next ten years. These are the people who will benefit quite a lot from this new policy: informed, proactive women in their late teens and early twenties who are not yet ready to settle down but want children in the medium-term future, and who are typically not going to have $500 to get the best birth control option for them unless insurance covers it.

With limited exceptions—I get that birth control can also be a treatment for certain medical conditions—it seems like birth control is just a predictable cost, not a risk to insure against.

The same is true of a huge amount of what people clamor for their so-called ‘insurance’ to cover. If ‘insurance’ were really insurance, it wouldn’t compensate anything whatsoever for business-as-usual doctor checkups or medical scans (for example).

I find this libertarian reasoning about how terribly “puzzled” about liberals position puzzling. You frame the debate this way:

1) inefficiently and indirectly make birth control affordable to the poor through a government mandate on the provision of health insurance. This you point out ends up primarily subsidizing mostly middle class people who are having sex at the expense of others who do not.

2) efficent, direct, (and implicitly much more honest) direct subsidies to the poor.

How can liberals possibly favor (1) over (2)? In no particular order:

1)you are assuming the provision of birth control is something that people who can afford to should pay for it. In other words, its a question of personal responsibility. My rejoinder is that unplanned pregnancies have lots of negative externalities, even if you are middle class, and that these externalities affect society at large. Thinking here is that the more you reduce the cost of birth control, the more you increase its usage and thereby reduce the chances of unplanned pregnancies in general. I think that’s a worth social goal but obviously reasonable disagree.

2) However, the above is an academic discussion. Your framing of this debate is a false choice, since its not a choice between provisioning public services to the poor versus inefficient subsidies to the middle class. The choice was between inefficient subsidies to the middle class that trickle down to the poor and the status quo. That is after all how the vast majority of our social safety net works.

This of course makes sense since the middle class is a large electoral voting block and the poor is a negligible one at all. If liberals want to advocate for government policy that benefits the poor, they need to address the middle class’s concern which is what’s in it for them. I am not even making a moral condemnation here, but a descriptive statement. For example, I bet universal healthcare would be VERY popular with the middle class if they didn’t have massive government regulations and tax subsides for employer provided insurance.

Also coming from the Libertarian perspective, this seems like a good area to compromise in and be pragmatic. But also, I believe that birth control is a moral choice. For Catholics who believe that birth control is immoral, they are now given a choice. Either go to prison for not paying your taxes, or pay for an immoral act. To me, that just seems unconscionable to force that upon someone. If we’re going to publicly provide this good, the taxpayer should be given a means to opt out, an extra box on the tax form. I’ll gladly check the box to pay that little bit extra and allow those who find it immoral to preserve their moral faith in their gov’t.

Or pay for an immoral act, or go without insurance? It’s not much of an improvement either way.

The problem is that ever since Health Insurance became something you *get* rather than something you *buy*, it’s been lumped into the same general “of course more is better” that government-style programs get. People don’t see the money that never hits their pocket.

Also, if providing free birth control *did* reduce total costs for the plan, don’t you think that the health insurance company would be doing it already?

When I read that headline I thought you meant that when you buy birth control, you can pay for an optional insurance policy that will compensate you in the event that you give birth to an unwanted child.

As some note, it’s possible that providing birth control would end up reducing costs on net by reducing the number of policyholder pregnancies. It’s somewhat doubtful to me whether this occurs when the copay is *zero* as opposed to merely relatively low. But in any event, I’d expect the insurers to be adequately motivated to find the right figure without a mandate.

Kpt- Do YOU really not get what I’m puzzled by? I understand how people use language; I don’t understand why it makes sense to pool *this particular cost* (and a fortiori, to mandate the pooling of this cost) as opposed to others. “Because people use language that way” is not a helpful answer.

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I understand the rest of what you’re saying, Julian – I don’t agree with what I think is your motivation, but I don’t think you’re arguing unreasonably.

But, this sentence: “…it seems like birth control is just a predictable cost, not a risk to insure against.” sounds to me like the canard I frequently hear from conservatives I know – “it’s supposed to be *insurance*, that’s the definition of the word.”

I argue that the term has more than one definition, and when we all say “health insurance” to each other, none of us is the slightest bit unclear about the fact that we’re not usually talking about socializing the risk of a catastrophe. We’re talking about the routine provision of ordinary health services.

Birth control seems to me to fit perfectly into this scheme. You may disagree that it should be part of the standard health package provided to people, I understand that (again, I disagree with you, but I understand where you’re coming from), but what does “a risk to insure against” have to do with it?

Do I need to have a quantifiable risk of dying of asthma before I should require that health plans cover an inhaler? Why is birth control different? I don’t have asthma myself, but it doesn’t confuse or concern me in the slightest that other people in my risk pool/health care service provisioning plan (oh, screw it – let’s just call it “health insurance” :)) do have it, and that they need to be provided with health care services.

kpt:
“You may disagree that it should be part of the standard health package provided to people, I understand that (again, I disagree with you, but I understand where you’re coming from)”

Julian:
“notwithstanding my generally libertarian sympathies, I even think it makes an enormous amount of sense to make subsidized—and in some cases free—contraceptives available to people who genuinely can’t afford them, if only because it’s likely to be a lot less costly to the public in the long run than supporting both the unplanned child and the parents who are a lot less likely to escape poverty once they’ve had that unplanned child. You might even want to set the income bar for the subsidy pretty high, to cover people who, though in no position to afford a child, could afford birth control but would be shortsightedly tempted to risk going without and spend the money on other wants.”

Julian does think it should be provided to people. As a form of redistribution funded through general taxation.

“Do I need to have a quantifiable risk of dying of asthma before I should require that health plans cover an inhaler?”
If the need for an inhaler is unexpected it can make sense to “insure” against it in the old-fashioned sense of the word. So the “plan B” pill would not be so different, but standard preventative measures would be.

kpt-
Either the conservatives you know are making the argument very badly, or you’re misunderstanding the real argument they’re making. It is not a moronic semantic argument: “We call it insurance, therefore only insurable risks should be covered, because we must show fidelity to the dictionary!” That would, indeed, be incredibly stupid—but I don’t think there are many people stupid enough to actually make THAT argument.

The point, rather, is that we CALL it insurance because the risk and unpredictability of health care costs are the whole reason—really the only reason—that we buy healthcare services in these “packages,” unlike 99% of the other goods we consume. Some predictable, routine services—like checkups—are covered because the insurer has an interest in seeing that the UNpredictable conditions are caught early, when they’re likely to be less expensive. But aside from the element of risk and unpredictability, why do you think healthcare services have to be purchased in the form of “standard packages”? Stuff that everyone predictably needs, but in types and quantities that are largely a matter of personal preference and discretion (i.e. food, clothing, birth control) we mostly just leave people to buy for themselves, with assistance to those who can’t afford it.

If someone is making a weird linguistic argument here, it sounds like it’s you: “Birth control should be provided because it’s part of health care, and that’s what health insurance provides—see, the word health is right in there!” Yeah, but WHY purchase birth control (but not food or clothing) this way?

“It just means the cost is now shared between women who do use it and those who don’t. ”

I think it would be more accurate to say that the cost is now shared between women who do use it, women who don’t use it, and MEN. I think this is a big part of why this is seen by many feminists as a victory. Until now, men and women both benefited from birth control, but this policy (combined with the ACA’s banning gender rating) means that men can no longer free ride and must share in the costs.

Well, insurance is like investment. You put some money in and you are guaranteed that you get more out later. In neither case is it a matter of calculating self-interest, it’s a matter of being a good citizen, a part of the nation’s great capitalist enterprise.

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